Citations

Background and purpose: Aortic stenosis (AS) poses significant healthcare challenges, particularly in aging populations like Lebanon. Aortic valve replacement (AVR) is the primary treatment; however the choice between transcatheter aortic valve replacement (TAVR) and surgical AVR (SAVR) varies based on patient-specific factors. This study aimed to compare clinical outcomes between TAVR and SAVR in patients with severe AS at a Lebanese tertiary care center. Methods: This retrospective study included 453 patients aged ≥60 with severe AS who underwent either TAVR or SAVR at the American University of Beirut Medical Center from 2011 to 2022. Primary outcomes were 30-day mortality and hospital readmission rates. Secondary outcomes included length of stay, complications, and changes in echocardiographic parameters. Statistical analysis included Chi-squared tests, t-tests, and propensity score matching. Results: Of the 453 patients, 306 underwent TAVR, and 147 underwent SAVR, with a mean age of 79.0 ± 6.8 years. The TAVR group had higher Society of Thoracic Surgeons (STS) scores (4.7 ± 3.2 vs. 2.6 ± 1.7; P < 0.001). TAVR patients had shorter hospital stays (2 [0-93] vs. 6 [4-41] days; P < 0.001), lower 30-day readmission rates (8.2% vs. 18.5%; P = 0.002), and similar all-cause mortality rates (hazard ratio [HR]: 0.69; 95% confidence interval [95% CI]: 0.14–3.42; P = 0.647). Post-procedural new-onset left bundle branch block (LBBB) was more common in TAVR group (13.0% vs. 0.6%; P < 0.001), and new-onset atrial fibrillation (Afib) was more frequent in the SAVR group (34% vs. 1%; P < 0.001). There were no significant differences in the rates of complete heart block (CHB) or pacemaker implantation. The effective orifice area index (EOAi) was higher in the TAVR group (1.2 ± 0.4 vs. 0.9 ± 0.2 cm2/m2; P < 0.001). Major bleeding complications were significantly lower in TAVR patients (7.9% vs. 65.8%; P < 0.001), with no significant differences in neurological events. Conclusions: Both TAVR and SAVR show comparable safety and efficacy, with TAVR offering advantages in terms of recovery time and bleeding risk. These findings support a tailored approach to procedural choice based on individual patient risk profiles.

Background: While patients may report painful or prominent hardware after tibial tubercle osteotomy (TTO), little is known about the frequency, associated factors, and outcomes after removal of symptomatic hardware. Purpose/Hypothesis: The purpose was to investigate the incidence of hardware removal after TTO due to pain or complications, factors associated with hardware removal, and postoperative outcomes after removal. It was hypothesized that clinical outcomes would be similar between patients who underwent TTO without hardware removal and those who underwent TTOs and subsequently hardware removal. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis was performed on patients who underwent TTO at a single institution from 2000 to 2023. Age at the time of the index surgery, sex, race, body mass index, number and size of screws, tibial tubercle–trochlear groove distance, and reason for hardware removal were collected retrospectively. Knee radiographs were reviewed for measurement of soft tissue–hardware distance. Patients were contacted via email to capture final patient-reported outcome measures (PROMs). A univariate logistic regression model was used to determine factors associated with hardware removal. Results: A total of 152 patients representing 171 knees were included. Of the overall cohort, 38 knees (22.2%) in 32 patients underwent TTO with subsequent hardware removal. The most common reason for hardware removal was anterior knee pain (79%). Compared with patients aged 11 to 20 years, patients aged 21 to 30 years demonstrated higher odds of undergoing hardware removal (OR, 3.67; 95% CI, 1.51-9.44; P = .009). Compared with a soft tissue–hardware distance of 0 to 4.9 mm, a distance of 10.0 to 14.9 mm demonstrated lower odds of hardware removal (OR, 0.24; 95% CI, 0.07-0.84; P = .027). Visual analog scale scores (0-10 scale) improved by a mean of 3.6 points after hardware removal ( P = .003). In patients undergoing hardware removal for pain, no difference in final PROMs was found compared with patients who underwent TTO without hardware removal. Conclusion: Hardware removal in patients undergoing TTO was mainly attributed to hardware-related pain/irritation. On average, pain scores improved after hardware removal. There was no difference in final PROMs between patients who had their hardware removed due to pain (eg, without any clinically relevant concomitant pathology) and patients who did not require hardware removal. Size and number of screws were not associated with a subsequent hardware removal procedure. The thickness of the soft tissue envelope overlying implanted hardware was inconsistently associated with lower odds of hardware removal.

Abstract Purpose Ultra‐low field MRI scanners have the potential to improve health care delivery, both through improved access in areas where there are few MRI scanners and allowing more frequent monitoring of disease progression and treatment response. This may be particularly true in white matter disorders, including leukodystrophies and multiple sclerosis, in which frequent myelin‐sensitive imaging, such as magnetization transfer (MT) imaging, might improve clinical care and patient outcomes. Methods We implemented an on‐resonance approach to MT imaging on a commercial point‐of‐care 64 mT scanner using a non‐balanced steady‐state free precession sequence. Phantom and in vivo experiments were used to evaluate and optimize the sequence sensitivity and reproducibility, and to demonstrate in vivo performance and inter‐site reproducibility. Results From phantom experiments, T 1 and T 2 effects were determined to have a negligible effect on the differential MT weighting. MT ratio (MTR) values in white matter were 23.1 ± 1.0% from 10 healthy volunteers, with an average reproducibility coefficient of variation of 1.04%. Normal‐appearing white matter MTR values in a multiple sclerosis participant (21.5 ± 6.2%) were lower, but with a similar spread of values, compared to an age‐matched healthy volunteer (23.3 ± 6.2%). Conclusion An on‐resonance MT imaging approach was developed at 64 mT that can be performed in as little as 4 min. A semi‐quantitative myelin‐sensitive imaging biomarker at this field strength is available for assessing both myelination and demyelination.

Diffuse large B-cell lymphoma (DLBCL) is the most prevalent and aggressive subtype of non-Hodgkin lymphoma comprising 30% to 40% of cases. While DLBCL frequently arises in the lymph nodes, up to 40% of cases originate in extranodal tissues. Primary splenic DLBCL is extremely rare comprising only ~1% of DLBCL cases and can be complicated by rare entities including gastrosplenic fistula (GSF). In contrast to DLBCL, polycythemia vera (PV) is a myeloproliferative malignancy. Polycythemia vera can transform into other hematologic malignancies including post-polycythemia myelofibrosis, but associations with DLBCL are uncommon. We present the first case of PV with concomitant primary splenic DLBCL complicated by GSF. While the majority of splenic lesions are benign, they have a broad differential diagnosis including malignant etiologies. Cystic or solid morphology, the number of lesions, and vascularity on imaging heavily guide further management. Due to concern for imminent massive upper gastrointestinal bleeding in the setting of GSF, our patient was diagnosed and managed with prompt splenectomy and gastrectomy. Percutaneous splenic biopsy is also a safe and effective diagnostic modality, but was deferred in our case given increased bleeding risk with PV. In conclusion, primary splenic lymphoma should be in the differential for a splenic mass regardless of whether the patient has a prior hematologic malignancy, and management should be prompt especially if complicated by a GSF.

Background: Total knee arthroplasty (TKA) and hindfoot reconstruction (HFR) are often used to treat osteoarthritis and deformities of the knee and hindfoot. Despite the proven clinical effectiveness of these treatments, postoperative patient dissatisfaction is high. The knee and ankle are adjacent joints in the lower extremity, and angular deformity of either joint is known to affect positioning of the anatomical and mechanical axes of the entire limb. Although it is understood this relationship exists, there are limited studies evaluating outcomes of ipsilateral procedures on patients with pathologies of both knee and hindfoot. This article aims to evaluate whether TKA or TAA/HFR sequencing influences postoperative outcome. The study hypothesis is that TKA prior to TAA/HFR results in lower reoperation. Methods: A retrospective chart review using Current Procedural Terminology ( CPT ) codes was performed encompassing all patients who underwent TKA in conjunction with a variety of hindfoot procedures. All procedures were performed at a single academic medical site between 2000 and 2022. Exclusion criteria included those patients not having both ipsilateral TKA and hindfoot procedures or those lacking conclusive postoperative data. The primary outcome of this study was to identify significant reoperations such as adjacent joint arthrodeses, hardware removal, or unrelated ipsilateral limb surgery. Secondary outcomes included identification of revision procedures including revision TKA or revision HFR and other postoperative complication data. Results: This study included 158 patients, with 79 patients in each group. In the TKA-first group, the mean follow-up time was 10.24 years (range, 1.10-22.42 years) and the mean time to HFR was 5.94 years. In the HFR-first group, the mean follow-up time was 9.01 years (range, 1.01-23.55 years) and the mean time to TKA was 5.51 years. In patients who underwent TKA first, the mean reoperation rate was not significantly different from those who underwent HFR/TAA first, 30.4% vs 19.0% ( P = .12). In patients who underwent TKA first, the rate of HFR reoperations (22.78%) was greater than TKA reoperations (7.59%) ( P < .01). The revision rate was higher in the TKA-first group (17.7%) when compared to the HFR-first group (6.3%) ( P = .03). Additionally, there were more revision HFR procedures in the TKA-first group (9/79) compared with the HFR-first group (1/79) ( P = .009). Conclusion: In contrast to the study hypothesis that TKA first would result in less reoperation, our study found that TAA or HFR performed before TKA had an overall lower complication rate. However, these findings should be interpreted cautiously as the sample size was limited. Level of Evidence: Level III, retrospective cohort study.

The gastrointestinal tract is made up of specialized organs that work in tandem to facilitate digestion. The colon regulates the final steps in this process where complex motor patterns in proximal regions facilitate the formation of fecal pellets that are propelled along the distal colon via self-sustaining neural peristalsis and temporarily stored before defecation. Historically, our understanding of colonic motility has focused primarily on distal regions, and the intrinsic reflex circuits of the enteric nervous system involved in neural peristalsis have been defined, but we do not yet have a clear grasp on the mechanisms orchestrating motor function in proximal regions. New approaches have brought to the forefront the unique structural, neurochemical, and functional characteristics that exist in distinct regions of the mouse and human colon. In this mini-review, we highlight key differences along the proximal-distal colonic axis and discuss how these differences relate to region-specific motor function.

Erdheim–Chester disease (ECD) is a rare non-Langerhans cell histiocytosis characterised by multiorgan pathological histiocytic infiltration. Cardiac involvement occurs in 40–75% of patients and increases mortality. A 55-year-old woman with chest pain and dyspnoea was found to have an interatrial septal mass and aortitis suspicious for ECD without other organ involvement. After two inadequate transcatheter interatrial biopsies were obtained using ultrasound guidance alone, diagnostic samples were successfully obtained using intraprocedural frozen section examination. The patient started genotype-targeted treatment with good response. Biopsy confirmation of ECD is required to guide treatment; however, cardiac biopsies are uncommonly performed when other organs are affected. Our unique case of isolated cardiovascular involvement highlights how frozen sectioning with multimodal intraprocedural imaging guidance can improve diagnostic yield of endomyocardial biopsies. It also highlights how diagnosis of rare conditions requires careful multidisciplinary evaluation of affected organs, procedural risk and diagnostic yield. The use of frozen sectioning can improve diagnostic yield of endomyocardial biopsies.

Abstract Biliary tract cancer (BTC) remains among the most challenging malignancies with a poor prognosis and limited treatment options, particularly in pretreated patients. As most patients experience disease progression after first-line treatment, effective second-line and subsequent treatments are required. Although the addition of modified FOLFOX (fluorouracil, leucovorin, and oxaliplatin) to active symptom control improved the overall survival of patients with progressing advanced BTC despite gemcitabine plus cisplatin treatment, its efficacy was modest. Moreover, most clinical trials demonstrated modest efficacy of molecular-targeted agents for molecularly unselected pretreated advanced BTC. Patients with advanced BTC carry a relatively high druggable genetic alteration rate and have shown promising responses to molecular-matched therapies targeting gene alterations such as FGFR2 fusions/rearrangements, IDH1 mutation, and HER2 overexpression/amplification. Additionally, tumor-agnostic approaches, including BRAF V600E, NTRK fusion, and RET fusion, have expanded the treatment options for some patients. Immune checkpoint inhibitors have shown limited efficacy as mono- or combination therapy in patients with pretreated advanced BTC. Therefore, developmental efforts have shifted to immune checkpoint inhibitor and other combinations such as vascular endothelial growth factor receptor inhibitors or radiation. In addition to refining combination strategies to enhance the therapeutic potential of immune checkpoint inhibitor, future research should focus on elucidating the tumor microenvironment. This review delineates the evolution of systemic therapies in patients with pretreated advanced BTC. By examining past developments and recent advances through prospective trials, it highlights novel approaches that may improve outcomes in this challenging disease.